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MALTREATMENT INVESTIGATION MEMORANDUM Minnesota Statutes, section 626.557, subdivision 1 states, “The legislature declares that the public policy of this state is to protect adults who, because of physical or mental disability or dependency on institutional services, are particularly vulnerable to maltreatment.”
License Number and Program Type: 1069431-H_CRS (Home and Community-Based Services-Community Residential Setting) Investigator(s): Gessner Rivas 651-431-3970 Suspected Maltreatment Reported: It was reported that on January 17, 2026, a staff person (SP) slapped a vulnerable adult (VA) across the left cheek which left the VA with a left cheek that was red and bottom left chin was a “little discolored.” Date of Incident(s): January 17, 2026 Nature of Alleged Maltreatment Pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (b), and Minnesota Statutes, section 626.5572, subdivision 15, and subdivision 2, paragraph (b), clause (1): Conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult. Summary of Findings: Pertinent information for this investigation was obtained remotely, including documentation from the facility and law enforcement records; and through four interviews conducted with the SP, two facility staff persons (P1 and P2), and the VA’s guardian (G). The VA was not able to participate in an interview. The VA was diagnosed with CHARGE syndrome (a genetic disorder affecting multiple organ systems), deafness, no vision in the left eye and limited vision in the right eye, so s/he was legally blind, scoliosis, and acid reflux. The VA had limited verbal communication and used simple American Sign Language signs. The VA enjoyed going out for treats like coffee. The VA’s Coordinated Service and Support Plan (CSSP) Addendum noted that the staff persons were to monitor the VA for hiccups because it could result in vomiting. The permitted actions section of the VA’s CSSP Addendum prior to the alleged incident noted that staff persons could tap the VA’s hand or shoulder, or place their hand gently on the VA’s face to redirect the VA. After the incident that same section was revised to include additional physical contact and details regarding permitted actions. Staff persons could use “gentle tap” on various parts of the VA’s body such as hands, head, face, shoulders, legs, arms, chin, and side of the VA’s jaw for various reasons outlined in the document. Reasons to do this included redirecting the VA from “snorting sinus” drainage where staff would tap the VA’s cheek when the VA made noises indicating s/he was going to do this and swallowing where staff would tap under the VA’s chin to prompt the VA to swallow. The SP provided the following information: · At the time of the alleged incident, the SP said that s/he used various methods to redirect the VA, such as waving or tapping, but that tapping was never the SP’s first choice. On January 17, 2026, the VA was doing a “sucking and clicking action” with her/his tongue which could lead to the VA vomiting. When the VA did this, staff persons were instructed to redirect the VA to do some other activity and tapping would help the VA understand what a staff person was trying to redirect. The SP stated that s/he tapped “firmly” on the VA’s cheek or under the VA’s chin; the SP stated it was firm enough to make some noise. · When asked to rate the tapping on a scale of one to ten, with one being light and ten being the equivalent of a slap, the SP stated it was between a three and a five and that s/he never tried to do it “super harsh.” The SP said that the tapping did not leave any mark but the VA was a little startled. The SP stated that s/he tapped the VA using four fingers but no palm. · After the incident the VA’s plan was changed to allow the type of tapping that the SP performed and staff persons were notified at a staff meeting. The SP noted that since the incident s/he was redirected to use one finger to tap the VA. P1 provided the following information: · P1 stated that the day of the incident after 2 p.m., P1 was nearby in a hallway and s/he heard the SP talking loudly with the VA who was doing a “snot” (snort) thing which could make the VA vomit, the SP was telling the VA to stop. P1 stated that s/he witnessed the SP slap the VA and it was loud enough to heard as well. The VA stood back and was visibly unhappy about it and appeared confused. P1 asked the VA if s/he was hurt and the VA said, “Yes,” and the VA’s eyes were watery. P1 said the SP slapped the VA only once. · P1 noticed that after the slap, the VA had a red mark, the bottom of the VA’s face was discolored which was still visible at the end of P1’s shift late in the evening; this was on the VA’s left side. · P1 took pictures of the VA’s face and sent them to P2 via text and stated that a mark could be seen on the VA’s chin in one of the pictures. P1 noted that at the time it was not in the VA’s plans but afterwards it was allowed to lightly tap the VA on the face; but believed that during this incident, the SP tapped the VA harder than s/he should have. Pictures of the VA’s cheek and chin provided by P1 showed no redness but slight discoloration under the chin. The discoloration did not appear to be consistent with the markings of a slap to that area of the face. P2 provided the following information: · P2 stated that s/he received a text message from P1 about witnessing the incident. P2 continued to text P1 about the incident. P1 sent P2 a picture of the VA’s face but P2 could not see anything out of the ordinary on the VA’s face. · Prior to the incident, staff persons were allowed to physically touch the VA’s face to prompt the VA but the VA’s plans were not very specific on that. After the incident the VA’s CSSP Addendum was revised; the permitted actions regarding physical contact to redirect the VA. The G provided the following information: · The G was notified of the incident within 24 hours via email. The G stated that gentle commands by touching the VA’s face were not unusual to redirect the VA. The G spoke with the VA via video call the day after the incident and did not see any injury on the VA’s face, there was no sign of redness or bruising. The G noted that the VA would not have the mental capacity to raise concerns about being slapped. · The G also spoke with P2 who reassured the G that there was no evidence of injury on the VA’s face. They spoke about how a gentle tap on the face was acceptable and had been used in the past but had not been part of the VA’s plan and adding that to the VA’s plan. · The G had no concerns about the care that the VA received at the facility where the VA had lived since s/he was 19 years old. In the past, the G would often make surprise visits but never had concerns regarding the VA’s physical well-being. According to law enforcement records, P1 provided the same account of the incident. P1 provided three pictures to law enforcement, two of which were of the VA. A law enforcement officer who reviewed the photos did not find any “obvious redness” or injury to the VA’s face. P2 informed law enforcement that the form of redirection used by the SP was added to the VA’s plan after the incident. The law enforcement officer interviewed the SP who provided the same account of the incident to this investigator. Law enforcement closed the report as “unfounded.” Facility documentation showed that the SP and the P1 each received training on the Reporting of Maltreatment of Vulnerable Adults Act, on the facility’s policies, and on the VA’s plans prior to the incident. Conclusion: A. Maltreatment: When trying to redirect the VA from a “sucking and clicking action” which could make the VA to vomit, the SP “firmly” tapped the left side of the VA’s face from cheek to chin, using four fingers. The SP stated it was not “super harsh” and did not leave a mark but the VA was startled and it made a sound. P1 stated that s/he heard the SP getting loud with the VA and saw the SP slap the VA on the face, loud enough that it could be heard. The SP, P1, and P2 stated that the VA’s plan at the time did not allow for any kind of tapping on the VA’s face to redirect the VA. Although P1 stated that the SP slapped the VA and there was a red mark, the photo P1 took of the VA’s face did not show a red mark, only a discolored area that was under the VA’s chin which was not red and not consistent with a slap mark. However, even though the SP stated s/he made contact with the VA’s face to redirect the VA, who was deaf, from a behavior that would cause the VA to vomit, given that both the SP and P1 stated the SP’s contact with the VA’s face was audible, and that the VA said it hurt, there was a preponderance of the evidence that the SP’s conduct was not accidental and would be reasonably expected to produce pain. It was determined that physical abuse occurred (conduct which is not an accident or therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress including, but not limited to: hitting, slapping, kicking, pinching, biting, or corporal punishment of a vulnerable adult). B. Responsibility pursuant to Minnesota Statutes, section 626.557, subdivision 9c, paragraph (c): When determining whether the facility or individual is the responsible party for substantiated maltreatment or whether both the facility and the individual are responsible for substantiated maltreatment, the lead agency shall consider at least the following mitigating factors: (1) whether the actions of the facility or the individual caregivers were in accordance with, and followed the terms of, an erroneous physician order, prescription, resident care plan, or directive. This is not a mitigating factor when the facility or caregiver is responsible for the issuance of the erroneous order, prescription, plan, or directive or knows or should have known of the errors and took no reasonable measures to correct the defect before administering care; (2) the comparative responsibility between the facility, other caregivers, and requirements placed upon the employee, including but not limited to, the facility’s compliance with related regulatory standards and factors such as the adequacy of facility policies and procedures, the adequacy of facility training, the adequacy of an individual’s participation in the training, the adequacy of caregiver supervision, the adequacy of facility staffing levels, and a consideration of the scope of the individual employee’s authority; and (3) whether the facility or individual followed professional standards in exercising professional judgment. The SP was trained on the Reporting of Maltreatment of Vulnerable Adults Act. Therefore, the SP was responsible for maltreatment of the VA. C. Recurring and/or Serious Maltreatment: The Office of Inspector General is required to evaluate whether substantiated maltreatment by an individual meets the statutory criteria to be determined as “recurring or serious.” Individuals determined to be responsible for recurring or serious maltreatment are disqualified from providing direct contact services. Minnesota Statutes, section 245C.02, subdivision 16, states: “Recurring maltreatment” means more than one incident of maltreatment for which there is a preponderance of evidence that maltreatment occurred and that the subject was responsible for the maltreatment. Minnesota Statutes, section 245C.02, subdivision 18, states: "Serious maltreatment" means sexual abuse, maltreatment resulting in death, neglect resulting in serious injury which reasonably requires the care of a physician whether or not the care of a physician was sought, or abuse resulting in serious injury. For purposes of this definition, "care of a physician" is treatment received or ordered by a physician, physician assistant, or nurse practitioner, but does not include diagnostic testing, assessment, or observation; the application of, recommendation to use, or prescription solely for a remedy that is available over the counter without a prescription; or a prescription solely for a topical antibiotic to treat burns when there is no follow-up appointment. For purposes of this definition, "abuse resulting in serious injury" means: bruises, bites, skin laceration, or tissue damage; fractures; dislocations; evidence of internal injuries; head injuries with loss of consciousness; extensive second-degree or third-degree burns and other burns for which complications are present; extensive second-degree or third-degree frostbite and other frostbite for which complications are present; irreversible mobility or avulsion of teeth; injuries to the eyes; ingestion of foreign substances and objects that are harmful; near drowning; and heat exhaustion or sunstroke. Serious maltreatment includes neglect when it results in criminal sexual conduct against a child or vulnerable adult. It was determined that the substantiated abuse for which the SP was responsible did not meet statutory criteria to be determined as recurring because it was a single incident or serious because it was not determined if the SP’s actions resulted in a mark on the VA’s face. Action Taken by Facility: The facility completed an Internal Review which determined that its policies and procedures were adequate and followed but the VA’s CCSP Addendum was revised to identify parts of the VA’s body that could be tapped for redirection, and staff persons were retrained. Action Taken by Department of Human Services, Office of Inspector General: The SP was not disqualified from providing direct care services as a result of the maltreatment determination in this report. However, the SP was notified by the Office of Inspector General that any further substantiated act of maltreatment, whether or not the act meets the criteria for “serious,” will automatically meet the criteria for “recurring” and will result in the disqualification of the SP. The determination that the SP was responsible for maltreatment is subject to appeal.
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